Remote Acute Extradural Hematoma Formation after Ventriculoperitoneal Shunt - A Rare Occurrence

Formation of acute epidural hematoma after Ventriculoperitoneal shunt insertion is rare in adults, more so at a site remote from the site of shunt insertion. We are presenting such a rare occurrence and discussing possible factors involved in this complication. A 35-year-old male was diagnosed with a third ventricular colloid cyst with hydrocephalus. A Ventriculoperitoneal medium pressure shunt was placed through right Keen point burr hole and the patient developed a right frontal extradural hematoma on the 4th post-operative day which was subsequently evacuated by craniotomy and the patient recovered fully thereafter. Acute extradural hematoma is a potentially life threatening complication. High index of suspicion, precautions during shunt insertion and early detection can prevent mortality and severe morbidity in these cases.

Personality Psychopathology in HIV Infected Patients.

Introduction: Given the magnitude of the problem and the multiple physical and psychological stressors that persons with HIV face in India, a study was planned to assess magnitude of substance abuse, and extent of personality psychopathology in HIV positive patients attending A.R.T. clinic at P.B.M. Hospital, Bikaner (Raj.). Aims: To assess and identify the extent of personality psychopathology in HIV patients Material and Method: 50 new seropositive patients without any severe medical illness, CD4 count above 350 and not on Antiretroviral Therapy were selected for study from ART Centre, PBM Hospital, Bikaner during 1 January 2010 to 31st December 2010. Personality psychopathology was assessed in study subjects for inter group comparison on various parameters like drug abuse, sex, etc., and other socio–demographic data on a self designed Performa and International Personality Disorder Examination (IPDE). Data were analyzed using appropriate statistical methods. Results: 77 % [14 out of 18] male HIV positive patients with substance abuse had disorder level of personality psychopathology, compared to 36% [4 out of 11] male HIV positive patients without substance abuse. 17 female patients out of 21 had only trait level of personality psychopathology. Conclusion: Majority of patients with substance abuse had co-morbid personality disorder and therefore it suggests that HIV infection may be consequent to basic personality problem.

Psychiatric Disorders in HIV Infected Patients.

Introduction: Psychological and psychiatric issues associated with HIV infection have received considerable attention in the last decade owing to the emotional impact of the disease and its effect on an individual’s personal, sexual, occupational social and emotional life. Aims: To study the phenomenology of psychiatric disorders in relation to HIV infection. Material and Method: 50 new seropositive patients without any severe medical illness,CD4 count above 350 and not on Antiretroviral Therapy were selected for study from ART Centre, PBM Hospital, Bikaner during 1 January 2010 to 31st December 2010. Equal number of attendants of patients were also assessed on same parameter as control group after recording socio–demographic data on a self designed Performa, Montgomery Asberg Depression Rating scale (MADRS), Hamilton Anxiety Rating Scale (HARS) and Brief Psychiatric Rating Scale (BPRS) were administered. Data were analyzed using appropriate statistical methods. Results: 8 out of 18 (45%) male HIV patients with substance abuse reported moderate–severe tension, 1/3 of patients exhibited moderate–severe depression and 15 (84%) were moderate to severely anxious. Among known drug abuse patients, 7 (64%) had moderate to severe anxiety and depression, 8 (72%) felt moderate to severe tensions. All males were moderate to severely hostile. Psychopathology was more frequent in females. Where tension, moderate to severe anxiety and depression were present in 90% of patients. Conclusion: Results indicate that the 65–85 % of non drug abuse male suffer from moderate to severe psychopathology,and the psychopathology in drug abusers is approximately 45% .The females were the worst sufferers.

Role of Personality and Stress in the Genesis of Bipolar Disorder - Mixed States: "Could it be a solution to the Diagnostic confusion prevailing in this disorder? (Part II)" .

Role of temperamental predisposition in the development of Mixed States is a relevant factor. Mania seems to arise from a hyperthymic background and Mixed States seems to arise from a depressive disposition. Aims: To compare the personality pathology and distribution of stress of patients of mixed states distributed according to the number of standardized criteria fulfilled and with the pure manic group. Materials and methods: Out of 214 bipolar disorder- current episode manic patients diagnosed as per DSM IV TR ,admitted in psychiatry ward of P.B.M. Hospital, Bikaner from 1st Jan 2007 to 31st Dec 2007,64 patients were randomly selected. Young’s Mania Rating Scale and Montgomery Asberg Depression Rating Scale were applied to these patients and 32 patients were assigned to mixed states on displaying one or more depressive symptom on MADRS, excluding decreased sleep. Rest 32 patient were assigned to pure manic group displaying no depressive symptoms. Presumptive Stressful Life Event Scale was applied to find out any stress in the lifestyle of the sample and International Personality Disorder Examination was applied on the third follow up visit. Results: Patients with personality psychopathology and stress met 3 or more criteria as compared to those with personality psychopathology without stress (p<0.01). Disorder level personality psychopathology, especially anxious disorder level personality, was significantly higher in mixed group patients as compared to pure manic patients(p<0.02).Meeting more criteria for mixed mania also meant higher scores on MADRS(p<0.01) Also patients meeting more than 3 criteria for mixed states had a significantly higher duration of hospital stay than those meeting less than 3 criteria(p<0.02) Conclusion: Mixed states is a dimensional diagnosis, higher the vulnerability in terms of disorder level personality psychopathology higher is the MADRS scores and greater episode duration.

Major Depressive Disorder: Part-I: Personality and Phenomenology.

Objectives: To study the phenomenological variations in context of personality psychopathology in Major Depressive Disorder patients. Methods:36 indoor patients of psychiatry ward of tertiary level service out of total 168 admitted patients from Ist January 2008 to 31st Dec. 2008 diagnosed as Major Depressive Disorder (as per DSMIV TR) . Socio-demographic data on a self-designed Performa, Montgomery Asberg’s Depression Rating Scale (MADRS), Hamilton Anxiety rating scale (HARS)and Presumptive Stressful Life Event Scale(PSLE) were applied to these patients and they were observed every alternate day till discharge. International Personality Disorder Examination (IPDE) was applied on their third follow-up visit, which ranged from 6 to8 weeks. Results: Sociodemographic variables by enlarge didn’t make a difference in MADRS score. MADRS score was significantly higher with increasing episodes of illness. Personality disorder patients had significantly higher MADRS score than Double traits (t=3.47, df=27, p<0.01) and Single trait (t=4.056, df=23, p<0.001) personality psychopathology. Higher level of depression in Personality disorder patients in all components of depression like sadness, reduced sleep pessimistic and suicidal thought etc were reported. Presence of stress with personality psychopathology added greater severity to depression. Conclusion: Our study brings out constitutional vulnerability with adverse environmental conditions were associated with higher level of psychopathology.

Major Depressive Disorder: Part-II -Comorbid Anxiety Disorders.

Objective: To demonstrate that Anxiety Disorder comorbidity is reflection of underlying common risk factors (Anxiety proneness) in Major Depressive Disorder patients and may not be a separate disorder. We hypothesized that “Anxious personality traits or disorders under stress take the form of state that is Anxiety Disorders”. Methods:36 indoor patients of psychiatry ward of tertiary level services, out of total 168 admitted patients from Ist January 2008 to 31st Dec. 2008 diagnosed as Major Depressive Disorder (as per DSMIV TR). Socio-demographic data on a self-designed Performa, Montgomery Asberg’s Depression Rating Scale (MADRS), Hamilton Anxiety rating scale (HARS) and Presumptive Stressful Life Event Scale (PSLE) were applied to these patients and they were observed every alternate day till discharge. International Personality Disorder Examination (IPDE) was applied on their third follow-up visit, which ranged from 6 to8 weeks. Results: High level of co-existence of Anxiety disorder 29(80.5%) in the study sample, 11 patients (30.55%) of Major Depressive Disorder had personality disorder level of psychopathology and 18(50%) patient of Major Depressive Disorder had double or more personality traits psychopathology and there were 7(19.45%) patients of Major Depressive Disorder had only single trait personality psychopathology. Conclusion: This work support the gene environmental diathesis where vulnerable person under stress develop Axis I disorder which are considered currently as co morbid disorders.

Co-Morbidity of Personality Disorders and its Impact on Phenomenology and Treatment Response in Bipolar Disorder Patients.

Aim:To study the comorbidity of personality disorders and its impact on phenomenology and treatment response in bipolar patients. Methods:40 indoor patients of psychiatry ward of P.B.M. General Hospital out of total 437 admitted patients diagnosed as Bipolar Disorder – Manic or Mixed were randomly selected. Young’s Mania Rating Scale (YMRS), Montogomery Asberg Depression Rating Scale (MADRS) and Presumptive Stressful Life Event Scale (PSLE) were applied to these patients and they were observed every alternate day till discharge.. International Personality Disorder Examination (IPDE) was applied on their first follow-up visit after recovery. Since the major aim was to observe the routine response pattern of phenomenology in Bipolar I patients and considering wide variabilities in treatment strategies of clinicians, we decided to consider the naturalistic method, the response to the best treatment considered by the treating physician Results : Borderline disorder level personality psychopathology was noticed in 32.5% of the whole sample .Anxious and Impulsive traits came a close second with 30% of the sample demonstrating the combined trait. Anxious disorder was seen in 3 patients that is 7.5% of the sample and Anxious, Impulsive and Anti-social traits were seen in 3 patients (7.5%).5 patients (12.5%) demonstrated anxious traits,3 patients (7.5 %)had impulsive traits and 1 patient had histrionic traits. Hospital stay of patients with Borderline personality disorder versus others with trait level psychopathology was significantly higher. (t=9.40, d.f. =38, p<0.000) Electro- Convulsive Therapy was administered to a significantly higher number of patients with personality disorder level psychopathology than to trait level personality psychopathology (X2=6.856, d.f.=1, p<0.01). Borderline Disorder patients had significantly higher YMRS score than single (t=3.348, d.f.=20, p< 0.001) and double trait t=3.58, d.f.=26, p<0.001) patients.

Bipolar Disorder - Mixed States: A Diagnostic Dilemma (Part-I).

There is a large difference in classifying Mixed States according to the prevailing standardized classifications because of the differential focus of the various criteria in identifying Mixed States. Aims: To assign the Mania With Depressive symptoms patients in different groups and to compare the phenomenology, personality profiles and psychiatric co-morbidities of these various groups so generated. Material and Methods: 64 patients were randomly selected from the 214 Bipolar Disorder – Current episode Manic (as per DSM IV TR9) patients admitted in Psychiatry ward of P.B.M. General Hospital,Bikaner from 1st Jan 2007 to 31st Dec. 2007. After recording socio-demographic data on a self-designed Performa, Young’s Mania Rating Scale (YMRS)and Montgomery Asberg Depression Rating Scale (MADRS) were administered on day 1,3,5,7 and 9 till discharge.32 patients were assigned to Mania with Depressive Symptoms on displaying 1 or more depressive symptom, excluding decreased sleep.32 patients were assigned to Pure Mania group who displayed no Depressive symptoms. Results: 30 patients(94%) could be assigned to Mixed states according to Vienna Criteria,25(78%) could reach the diagnosis of Mixed States as per Cincinnati criteria, another 17(53%) were assigned to Mixed States as per Pisa San Diego Criteria.ICD-10 could identify 5 patients(16%) and DSM IV TR appeared to identify the least that is 3 patients(9%) Conclusion: Concept of MS couldn’t be better explained with these existing criteria because some patients meeting one criterion are not meeting others.

Rheumatoid Arthritis: Phenomenology, Personality Profile, Stress and their Inter-Relationship.

The purpose of this study was to study the psychiatric morbidity of Rheumatoid Arthritis and to look for an association between disease parameters and personality dimensions of Rheumatoid Arthritis patients. Methods: 40 patients were selected from Rheumatoid Clinic of P.B.M.Hospital,Bikaner as per Association of Rheumatoid Arthritis (A.R.A.) revised criteria. The ICD-10 Module of International Personality Disorder Examination (IPDE),Social And Occupational Functioning Assessment Scale (SOFAS),Hamilton’s Rating Scale for depression(HAM-D),Presumptive Stressful Life Events Scale(PSLE) were administered to these patients .Bivariate statistical methods were used to find association between illness variables and psychological dimensions. Group differences were analyzed by students T-test and ANOVA. Results: Rheumatoid Arthritis patients with psychiatric morbidity showed higher R.A. severity (p<0.02), swan neck and valgus deformity (p< 0.05), more number of joints involved (p<0.01), smaller joints (metacarpo-phalangeal and inter-phalangeal) involvement (p<0.05), presence of C - reactive protein in blood samples (p<0.01). Majority of patients who had personality psychopathology also reported stress in preceding one year period. Personality level psychopathology either alone or in combination is present in 17 patients that is 42.5 % of the sample. Patients with single personality trait psychopathology were better in comparison to severe personality psychopathology in terms of number of joints involved, joint deformities, social and occupational functioning and psychiatric morbidity. Conclusion: Preliminary findings suggest that the severity of Rheumatoid Articles correlates with psychiatric morbidity.

Personality Profile, Stress and their Inter-Relationship.

The purpose of this study was to study the psychiatric morbidity of Rheumatoid Arthritis and to look for an association between disease parameters and personality dimensions of Rheumatoid Arthritis patients. Methods: 40 patients were selected from Rheumatoid Clinic of P.B.M.Hospital,Bikaner as per Association of Rheumatoid Arthritis (A.R.A.) revised criteria. The ICD-10 Module of International Personality Disorder Examination (IPDE),Social And Occupational Functioning Assessment Scale (SOFAS),Hamilton’s Rating Scale for depression(HAM-D),Presumptive Stressful Life Events Scale(PSLE) were administered to these patients .Bivariate statistical methods were used to find association between illness variables and psychological dimensions. Group differences were analyzed by students T-test and ANOVA. Results: Rheumatoid Arthritis patients with psychiatric morbidity showed higher R.A. severity (p<0.02), swan neck and valgus deformity (p< 0.05), more number of joints involved (p<0.01), smaller joints (metacarpo-phalangeal and inter-phalangeal) involvement (p<0.05), presence of C - reactive protein in blood samples (p<0.01). Majority of patients who had personality psychopathology also reported stress in preceding one year period. Personality level psychopathology either alone or in combination is present in 17 patients that is 42.5 % of the sample. Patients with single personality trait psychopathology were better in comparison to severe personality psychopathology in terms of number of joints involved, joint deformities, social and occupational functioning and psychiatric morbidity. Conclusion: Preliminary findings suggest that the severity of Rheumatoid Articles correlates with psychiatric morbidity.

Out Come of Bipolar I (Mania) Disorders, In Relation to Catatonic Symptoms.

The purpose of this study was to understand and probably explain the variability in symptomatology particularly with presence of catatonic symptoms and treatment response to lorazepam in mania. Methods: 52 patients of bipolar disorder were selected from admitted patients in psychiatry ward from P.B.H. Hospital, Bikaner. Structural Clinical Interview for DSM IV patient version (SCID-P) item Young Mania Rating Scale, 23 item Bush Francis Catatonia Screening Instrument and Rating Scale. 43 item Presumptive stressful Life Event Scale, were administered. Statistical tests were performed using SPSS version 9.0 were Pearson’s correlation Chi square analysis, test, ANOVA. Results: Only 3 patients out of 14 patients of first Manic episode showed good outcome. Patients with history of multiple episodes had shown better outcome (X2 = 11.59, df = 1, p < 0.00) The authors noted that the presence of catatonic symptoms (X2 = 17.76, df – 2, p < 0.001), high catatonic scores (F = 37.18, df = 2, 49, p < 0.000), and high reduction in catatonic score after Lorazepam challenge were associated with better outcome. There was strong negative correlation between index, catatonic and Mania Scores in grade I and grade II outcome category, (p < 0.000). Conclusions: This is a preliminary study to suggest that the presence of catatonic symptoms had better outcome in bipolar patients.

Outcome of Bipolar I (mania) disorders, In Relation with Personality Profile.

This prospective semi structured study evaluated the relations of symptomatology and outcome of bipolar manic patients with personality vulnerability. Methods: 52 patients of bipolar (mania) disorder, out of total 430 admitted patients in psychiatry ward, from January 10, to July 9, 2005 were included in the study. The patients with organic diseases or on any drugs for last two weeks were excluded from the study. All the patients were diagnosed as per ICD-10 diagnostic criteria. Patients of bipolar mania were administered Young Mania Rating Scale (YMRS) to assess the severity of mania. The personality traits and disorders were assessed by the help of ICD-10 module of International Personality Disorder Examination (IPDE). The stress in preceding one month was evaluated by using 41 items Presumptive Stressful Life Event Scale. Initial response to lorazepam was monitored to determine outcome categories. Results: The clinical and demographic variables of the study sample were analyzed with initial response to IV lorazepam as quick responder (grade-I), moderate and poor responders (grade II, III). Sociodemographic variables like marital status (x2 = 1.62, df = 2, NS) and education status (X2 = 4.57, df = 2, NS) did not approach to statistical significance in outcome. However, the outcome of the low income group patients was significantly better ( X2 = 16.84, df = 2, p < 0.001). Out of 14 (26.92%) patients of first manic episode, only 3 patients showed good response to initial lorazepam treatment (Grade I) and 9 and 2 patients assigned outcome category II and III respectively. Patients with history of multiple episodes had shown better response (X2=11.59, df=1, p<0.001, highly significant). Presence of stressful life events was positively correlated with better response to lorazepam treatment (x2==6.73, df=1, p<0.01 significant). Anxious (avoidant) or dependent traits alone or in combination with emotionally unstable personality traits in manic patients significantly determined better episode recovery with lorazepam at one hand proneness for relapses on the other hand.

A new hypothesis for faster healing of fractures in head injured patients.

A new hypothesis has been proposed to explain excessive callus formation seen after injury to brain or spinal cord. Nervous tissue is very active metabolically and when damaged or inflammed it extracts, utilises and inactivates most of the corticosteroids and other anti-inflammatory substances present in the blood. Therefore now very little active corticosteroids are left to exhibit the inhibitory effect on callus formation. This leads to faster fracture healing with excessive callus formation in head or spinal cord injured patients.

Coronary-prone behaviour pattern and myocardial infarction.

Seventy five patients with acute myocardial infarction (MI) and forty matched control subjects were assessed for coronary-prone behaviour pattern by a self administered scale. Analysis of the results showed a higher incidence (P < 0.001) of type A behaviour pattern in acute (MI) patients, as compared to controls.

Prevalence and pattern of mental health problems.

Three hundred and forty eight children of age group 5-15 years were studied. A reporting questionnaire was administered to the parents and then affected children were examined in detail by history, physical examination and mental status examination. Fifty out of 348 children were having mental health problems. Male and first born children were affected more. Common problems observed were poor scholastic performance, enuresis, hyperkinetic syndrome, speech disorders and sleep disorders. In males, poor scholastic performance, hyperkinetic syndrome and temper tantrums were common while in females enuresis, speech disorders and hysterical symptoms were more frequent. Among the adverse perinatal factors of etiological importance low birth weight, difficult deliveries, birth injuries, delayed cry, neonatal jaundice and convulsions were common. Predominant psychosocial stress factors were quarrels between parents, separated parents, deaths of parents, siblings or relatives and chronic illness in the family.